Diabetic Recipes
What you don't want to hear from your diabetes educator is "hmm, good question." That is, unless it's immediately followed by a good answer.
There has been a burning question of ours since Charlie started on the pump back in September of 2006. During that time, we posed the question to several different people along the way, but never really got a clear answer.
So I present this burning question to you - the true gurus of diabetes.
How can Charlie skip a meal if he wanted to? Is this a mythical notion or do people out there actually achieve this? If Charlie didn't eat something two to three hours after a bolus, he would most certainly go low. I'll ask you exactly what I asked the doctor and nurse practitioner the other day.
How can Charlie come back into range two hours after a meal bolus and then just stay there when 50 to 60 percent of that bolus is still active or "on board?" How could we just leave him alone? Even if you counter by dropping the basals, there's still a massive amount of active insulin to contend with. How is it done? I'd really love to hear your thoughts on this. If we decrease the bolus we're then dealing with him staying high for three to four hours until finally falling into range. That's no good either.
The pump brochures with "real-life" situations only frustrate me more.
While moving into her new apartment, Tara met Keith, her new next-door neighbor and his adorable schnauzer named Louie. Keith invited her to stop over later that night for some pizza with friends. Tara arrived at the party at about 7 pm, the time she would normally have dinner. She decided to skip dinner, though, thinking that she'd hate to have pepperoni pizza breath if she ended up making out with Keith on the balcony. Did I mention, Keith was like smokin' hot? With the pump, Tara didn't have to follow a strict meal schedule. The pump put Tara in control.
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December 2nd, 2008
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01-11-2008 5:28 PM EST by Carey Potash
Categories: Type 1 Insulin & Pumps Children Food Real Life
Tags: Active insulin skipping meals
Views: 2055
Categories: Type 1 Insulin & Pumps Children Food Real Life
Tags: Active insulin skipping meals
Views: 2055
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Carey is a full-time hater of diabetes. The benefits stink. His 6-year-old son, Charlie, was diagnosed with type 1 diabetes when he was 22 months old. Carey's parenting humor has appeared in various websites and print magazines. He resides in the suburbs of Philadelphia with his wife and three children. (Read More)
Latest Posts: Thankful | Diabetic in the Mist | The Adventures of Gleevec and Sutent
Scott lives an active life with type 1 diabetes. Aiming to stay on top of his unexpected diagnosis, he puts a strong foot forward to stay in control.
Living life in the sun and fulfilling his dreams, Scott tries to educate himself, and others, on the unquestionable possibilities of a life with type 1 diabetes.(Read More)
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The flexibility that I've found with using a pump is that I don't have to bolus for a meal until right before I start eating. In the pizza-example, I wouldn't take the insulin for the food until I actually sit down to eat it. Otherwise I think you're right, if you bolus for the meal and then either delay or outright skip eating it, you would run into a lot of problems from the insulin and lack of food.
Maybe it's the way you're presenting the question to the team because you're asking two different questions as though it were the same thing. (that's how it's presented in my mind).
First thing, if he skips a meal, then yes you need to cut down the basal, but you still need to test him at the time when his meal was supposed to be and his glucose number would be what you would determine how much you need to cut him back.
If he doesn't eat 2-3 hours after a meal, the bolus should take care of the meal he ate and after 3 hours he should be at his target number and the basal takes over after that point.
What happens after he eats dinner, does he get a snack? And what about overnight. He doesn't eat every 3 hours during the course of a 24 hour period.
If you'd like, email or even call us. Jeff said he'd want to talk to you about it (we were conferring with each other as I was typing this) over the phone as computers "aren't his thing" LOL. Let me know and I'll email you our number.
From my experience, with a pump, I can skip a meal without any problems. Being a student I don't have a set schedule most days so my meal times change daily. As long as the basal rates are 'correct' he should be able to skip a meal and stay in range.
I am a little confused by your question. Why are you giving him the bolus? When I eat, I bolus to cover the carbs I eat. Then if I find I am high at some point during the day, I give myself a bolus only to cover the high. If you are giving your son a bolus to cover a high BG, and he ends up going low, then your math equation for highs needs to be changed.
I guess I wasn't so clear. I'm referring to a bolus given to him for a meal. Let's take breakfast for example. He wakes up at 120. Has breakfast. Has bolus to cover breakfast carbs. Two hours later he's 112 and he has plenty, plenty, plenty active insulin from that breakfast bolus. We find that it lasts at least 5 hours, maybe slightly more. So, it's only been 2 hours and we're forced to give him a snack because he'll go low otherwise. I realize that obviously means that the carb ratio and the basals are likely not set right, but over the last year and four months, we've tried so many combinations and just haven't gotten it right. It's been one extreme or the other. Either he falls into range in two hours yet has way too much active insulin remaining or he's high all morning and finally falls into range after 3-4 hours. We prefer to have him back in range after two hours, but as you can see that hasn't been ideal.
Does that make sense? Thanks a lot for all your comments and suggestions. Thanks Shannon. Maybe I'll call you guys if we don't see progress with our new pump team. We spoke to someone who seemed pretty confident that she can help us get it right.
I'm new here and I realize that your post is a little dated, but I presume you're still struggling with this. What you're describing is really the essence of the problem for all type 1's. You'll never get it perfect, but you can probably be 75% successful in keeping post-meal highs down and limiting lows. The problem is: in order to cover even a moderate amount of carbohydrate in the short term you have to take too much insulin for the longer term (5 hours). What you're doing now could be okay if you can predict the drop in bg and treat it before it gets too low, but you need to be certain that you've got the basics of his pump regimen dialed in. That is, you have to have the nighttime basal rate adjusted so that his waking bg is almost the same as his bedtime bg, (120 waking is too high) and so on for each specific period (morning, midday, evening, night). Then you need to know how much 1 unit of insulin will lower his bg when nothing else is a factor; how much 1 gram of carb will raise it; how many carbs 1 unit will cover. Because I limit my carbs I also know how many grams of protein 1 unit will cover. This is, for me, the key to limiting post-meal excursions, both high and low. How many carbs does he eat at a meal? What else goes into the meal? How active is he? How consistent is his schedule? There are really good books that deal with this problem. I don't know if it's appropriate to mention them here. I'd be happy to have a longer discussion with you about this if that would be helpful. I've spent a lot of time and energy solving this puzzle for myself with some success.
Hi
My concern is with the terms. First, I wear an insulin infusion pump and have skipped meals at different points in a day and have eaten meals at different point in a day. That is why I wear a pump. Basal: It is my understanding that this represents the flow rate of insulin into one's body to maintain a normal bllod glucose level of 70 - 110. It is important to understand that this is not a fixed rate and does vary across the entire 24 hour period. Next, I also have different basal, flow rates that are different based upon the active for a certain type of day. A bolus rrepresets the amount of insulin as a "shot" for a meal to match the carbs with the bolus. I find that checking my blood glucose levels at the 2 hour mark and the 4 hour mark are the best that I can do to in an attempt to maintain a normal blood glucose level. There are many meals that I can only guess at the carb count. The 2 hour marker and the 4 hour marked after eating allow me to make the necessary adjustments. If low add juice, if high prepare to have an additional bolus. I have discovered over time that certain foods will be low at the 2 hour mark and high at the 4 hour mark. Some food combinations have different patterns. The point is I check a both times to do what I can to maintain a blood glucose range within normal levels. Hope this helps as a real example of the day to day challenges.
Carey,
If you find out an answer that works for Charlie, will you share it with me?
Riley usually eats snack 2.5 to 3 hours after a meal. For example, he had breakfast at around 7 and he'll get snack at school at 9:30. But, if snack were skipped for some reason he would almost certainly go low. Then, he has lunch at 12:30 another snack at 3:30. Supper is at 5:30-6:00 and another snack around 8:30-9:00.
But, like Shannon says he goes all night without anything to eat and does OK. So, I guess the key is the basals during the day. I guess his basals are set up to take the snack into account?
I don't know. I don't mean to be so long-winded I just thought it was a great question.
Penny,
I think you're right when you say that the basals are set up to take the snack into account. When you set up his basals, did you let him snack while it was being done? Bren's nurse educator told us to eliminate snacking on the days we set up his basal rates in addition to a couple of days after while we test him to see if his basal rates are adjusted correctly.
As I'm typing all of these comments, I realize how much crap goes into setting up the pump. Ugh.
Patrick: Thanks a lot for your comments.
Penny and Shannon: Regarding the overnights, our problem isn't that he's not eating in the middle of the night. His basals will keep him fairly level once the bolus is finally a non-factor. It's getting to that point that's tricky for us. It's the between. It's the five hours of active insulin after that before-bed snack. So, we're fine once that active insulin runs it's course. Daytime is a whole different animal. He eats meal, snack, meal, snack, meal, snack during the course of the day, so obviously there's a bolus always at work. Sure, he could skip a meal, but not without us intervening in one of two ways - a juicebox to bring him up or a correction to bring him down. Would be nice if we could one day figure it out.
Hi Carey,
This may help. I utilize an Animas IR1250 infusion pump. My insulin is Apdria, a fast acting insulin. Do I eat 2-3 hours after eating? Yes. This is how I handle the issue. I bolus after the meal so that I can best count the number of Carbs in the meal. When having a snack, I have a snack that I can read the the carbs directly. I bolus for the specific carbs in the snack. I still test 2 hours later after the snack to check the status of the dinner and the snack. Hope this helps.
I am just curious to know what kind of insulin he uses. I use humalog and thought it should only last 3 hours. Does the same kind of insulin last different amounts of time in different people? If not, then maybe switching insuling could help too. 5 hours would be a long time to worry about a bolus. I would probably go low too if that were the case.
Charlie uses Humalog as well. I think the duration of effectiveness does differ from person to person. They say Humalog lasts 4 hours, but we've found that it's still kickin' in that fourth to fifth hour. Yeah, certainly makes it tricky.
Carey,
Riley is on NovoLog. We find that it's duration for him is about 3.5 hours.
One of the commenters said "I have discovered over time that certain foods will be low at the 2 hour mark and high at the 4 hour mark." I completely agree with this. Things that are high in fat will often cause me to go low at first, but then high later. To combat this, I usually do a "combination" bolus in my pump (Cozmo). You give only a percentage of the insulin up front (to reduce the 2 hour low), then the rest is given like an increased basal over a few hours (to reduce the 4 hour high). Maybe you could play around with the combo bolus to better match the insulin with the food.